​This position statement from the Neurocritical Care Society advises on what to do when faced with a patient with a devastating brain injury (in practical terms it relates to those patients for whom neurosurgery is not carried out). The gist is that early prognostication is not the right thing to do and that such patients should be admitted to an ICU (not necessarily a neuro-ICU) and reassessed over a period of up to 3 days. The rationale is that early prognostication is unreliable (this review gives some background) and that by withdrawing life sustaining treatment we would be denying a real chance of life with full neurological recovery.

I’ve taken a while to get my head around this, but what follows are some of my thoughts. For a bit more reading, this paper is about to be published in JICS which discusses the same issue and also provides some case studies and a suggested pathway.

There is some sort of precedent for admission to ICU, in that guidance for prognostication after cardiac arrest has made us far more likely to admit all patients post ROSC (assuming the reason for the arrest is treatable). I write ‘some sort of’ precedent because, although both patient groups have potentially suffered cerebral damage, there is a difference in that the head injured patient has a CT showing gross structural damage, whereas post ROSC there is nothing so tangible. Perhaps if CT were able to show hypoxia associated changes instantly (which it can’t), a better comparison would be the head injured patient with a patient post-ROSC with gross ischaemia on CT.

The million-dollar question raised however is: Is the chance of survival with good function after devastating brain injury such that admission to ICU is in a patients’ best interests? (Ignoring that for any individual patient with any disease, this chance is unquantifiable with any accuracy, and we have no real concept of what threshold for admission is appropriate). It’s true there are certain disease states we have been unduly pessimistic about, leading to self-fulfilling prophecies; maybe this is one of them? As good an example as any is COPD; this paper was a ‘game-changer’ for many clinicians. Even ventilation with fibrotic lung disease isn’t always un-survivable - how we identify the patient with reversible features is difficult, but should we therefore offer ventilation to all? (This is a really good review). Does this guidance facilitate access to critical care for a patient group with a lower chance of favorable outcome than we would usually feel comfortable admitting?

We face these difficult admission decisions every day, taking into account cost as well as possible benefit. For the patient with end stage fibrosis the potential cost is a prolonged death with a high treatment burden. With the head injured patient, the potential cost is that but also something else; it is risking survival with poor neurological outcome. From the viewpoint of my own values and beliefs (which may be completely different to yours or those of my patient), this may be the worst possible outcome. The difficulty is of course that we have no idea what the actual cost for our individual patient will be.

These injuries are occasionally termed ‘un-survivable’, and in many cases that will be true – indeed the given definition of catastrophic brain injury is one that is a direct threat to life. One potential advantage of admission is that once death is recognised to be inevitable, I think an ICU can provide excellent end of life care. In America, 58% of people dying in hospital do so in an ICU (data from 2004), and whilst I don’t think a default of ‘doing everything until nothing more can be done’, or using critical care as a preferred place for palliative care is appropriate, this benefit can’t be denied. In any case, if we maintain that the intention is to identify recovery this can never be more than a secondary benefit so wouldn’t alter a decision whether to admit.

The elephant in the room is that admission to ICU will increase the likelihood of organ donation by non-survivors*, allowing time and discussion away from a busy emergency department. Some patients may in fact suffer brain death during this period of observation, which again is ‘favourable’ from a donation perspective. The statement is clear in that a desire or ability to donate should not be influential, but I think there will always be a perception that this conflict exists. Perhaps the best solution is to be open about it; to not let donation guide management but to not be apologetic about this benefit either (I don’t think the authors help themselves here by the number of times it is mentioned, almost as a running theme).

Overall I welcome this statement; it provides some clarity in a difficult area. I do think we need to be careful about how we apply it, so that our intentions are clear and that we don’t offer false hope. I think the key to this is honesty with yourself as to why you are admitting the patient, but perhaps even more importantly with the patient’s family. Telling a family that the situation suggests real and severe brain damage, and that there is a high chance of death but that we can’t be sure at this point in time is honest. Where this guidance shouldn’t be used is as justification to admit for palliation or to increase organ retrieval.

If a patient ultimately has a ‘good death’ and part of that death is fulfilling a wish to donate, after being given every reasonable opportunity to demonstrate neurological recovery, that to me is surely a good thing.

I've heard that certain areas of the UK have adopted this guidance as standard practice; hopefully we'll see their experiences published before long.​Finally, as a bit of a postscript, something about this does continue to confuse me however. If we can’t prognosticate early, why do we know that neurosurgery wouldn’t make a difference - or put another way, on what evidence is the decision to not operate so certain? There’s an earlier post on this site “bilateral fixed dilated pupils – should we transfer” that asks a similar question.

It's a difficult one for sure. We're heavily relying on family for a lot in these situations - trying to figure out whether the chance of survival with a full neurological recovery would be /to that patient/ worth the risk of survival with severe physical disability/dependency or in a minimally conscious state. This paper is definitely worth a read from that point of view: http://www.ncbi.nlm.nih.gov/m/pubmed/23278317/

As with most things I suspect we'll never find a 'right' answer, but I think we have to try and individualise these decisions as much as we can.

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Monica Jackson

16/5/2016 12:04:39 am

Much of this literature is inevitably very reminiscent of what has been published on prognostication post cardiac arrest. What seems clear is that for both conditions, this is an area where both clinicians and families currently must make decisions without good evidence and statistics to guide them. Until we have reliable prognostic signs we will always be treading a difficult path between over-treating and risking a prolonged death or poor neurological outcome, or under-treating and potentially withdrawing care on those who might have done well in the end.

We are moving away from the days of early WLST, but I think it is imperative that we recognise we are still operating in a fairly evidence-free zone. The potential long-term consequences for the patient (and family) of offering intensive care treatment in this situation are immense, therefore we must work towards collecting robust data about outcomes as a matter of urgency. There is certainly an issue with the self-fulfilling prophecy that comes with early palliation following DBI, but we mustn't move blindly towards a more optimistic management strategy without keeping a careful eye on the consequences.

I'm not sure whether ICNARC receives enough data to analyse these cases, or if they fall under another data collection similar to the national cardiac arrest audit?

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Claire

19/5/2016 09:52:27 am

I agree - in my eyes using 'survival' as the endpoint in these patients doesn't necessarily equate to a successful outcome. Similar to the arguments in the DECRA trial, are we merely generating a cohort of patients who would have died into patients who survive but with a poor neurological outcome.

Neuro units freely admit patients with DBI in order to facilitate organ donation which along with end of life care is something we can provide far better than the alternative, which in these patients is often a cubicle in A+E. It also gives time for the family to come to terms with the situation.

Fundamentally it will always remain a patient/situation/family specific decision but with the awareness that the admission would not necessarily be successful in terms of survival with a good outcome, but could be viewed as being successful in terms of organ donation or dignified death.

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laura

20/5/2016 09:35:50 am

This is an interesting area which hits upon the core of critical care and why we have all chosen it as a challenging and fulfilling career.
It forces clinical staff and relatives to revisit their ethical opinions and the wishes of their loved ones during an emotionally testing time. We must take all we know about this group at an individual level( beliefs, comorbidities, functional status ) and presentation (aetiology, clinical signs, imaging and other investigations eeg etc ) and integrate this with the evidence available ( which when you consider the above it is obvious that waiting or expecting studies looking at populations to tell us the "right" thing to do for an individual is never going to happen) and deliver it in a sensitive and accurate way, communicating all the nuances and potential outcomes to family.
However some guidance in this difficult area is as Pete says welcome and overdue. But I disagree with some of the statements:
I have always found it interesting that in many areas of medicine we undertake studies in patient populations to identify factors Which may be associated with poor outcome and we use these factors In addition to others during decision making for individual care planning. This is not unusual and is widely accepted. However in neurosurgery and to some degree neuro critical care despite good evidence of certain factors derived at a population level from well conducted studies being associated with poor outcome they are noted but put to one side as they state they are not applicable at an individual level. I have long wondered why this is the case here and not in other areas. if neuro critical care want good evidence of benefit you could question why they use ICP monitoring and de compressive craniectomy both of which do not have first class literature to support their enthusiastic application.( I am being obtuse but my point is valid we pick and choose the literature that suits to support decisions)
I would argue lots of the factors discussed in this document should be delivered on the ward to all patients ( ethical practice, good communication, support of surrogate decision makers) and that admission to critical care is not essential for this and if we are doing so then we need to address these issues on the ward to ensure all patients get this high quality care.
finally I agree with Pete ( FYI I too strongly support orgna donation ) I feel that there needs to be a clear separation of organ donation from this document as it can muddy the water when decision making and communicating. We are admitting someone to resuscitate and optimising brain function (done well this will be sufficient for future organ donation) observe and assess their progress. At the stage of realisation progress is not as hoped then we should explore orgna donation status.
obviously this area is contentious and above are my personal opinions but about which I am happy to be challenged and have further discussion.

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Laura

20/5/2016 09:42:14 am

Oh and another thing...........I think admitting patients to critical care allows us to exclude seizures as a potential confounding clouding of conscious level. Generalised convulsive status and non convulsive status is really common in this group, open to treatment within a general critical care environment and easy to exclude.
( that's all)